Krishna Patil

A selected review and personal experience with robotic prostatectomy: implications for adoption of this new technology in the United Kingdom

Robot-assisted laparoscopic prostatectomy (RALP) is a rapidly evolving technique for the treatment of localized prostate cancer. However, cynics point to the increasing role of market forces in the robotic revolution. As yet, Europe has not taken up RALP in large numbers and this may in part relate to the high level of expertise in laparoscopy previously gained. Furthermore, setting up a robotic programme is a major undertaking for many surgical units. This review discusses some of the challenges in the development of a robotic service drawn from personal experience within the United Kingdom. Furthermore, available data on RALP versus open and laparoscopic approaches are reviewed for surgical and cancer-related outcomes. Preliminary data appear to show an advantage over open prostatectomy with reduced blood loss, decreased pain and early mobilisation and shorter hospital stay. Most intra-institutional studies demonstrate better postoperative continence and potency with RALP; however, this needs to be viewed in the context of a paucity of randomized data available in the literature. There is no definitive data to show an advantage over standard laparoscopic surgery, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging: with continued experience, the hope is that results will continue to improve.

TRANSITION FROM OPEN TO ROBOTIC‐ASSISTED RADICAL PROSTATECTOMY

No one could have predicted the rapid growth of robotic-assisted radical prostatectomy (RARP), particularly in the USA where there are currently more than 500 da Vinci robotic systems in operation. While RARP constituted only 10% of the total volume of RPs performed by American Urologists 2 years ago, it is expected to increase to > 60% in 2007–8. Those who are sceptical continue to argue that this is just a reflection of marketing. Nevertheless, it is difficult to imagine so many surgeons and patients being lured to a procedure merely because of its financial implications. We can all remember a similar debate surrounding open RP (ORP) 10–15 years ago but now this procedure is widely regarded as the ‘gold standard’ against which all other surgical procedures for localized prostate cancer need to be compared and the only one that has been proven in a randomized trial to reduce mortality compared with watchful waiting [1].

Overcoming the challenges of robot-assisted radical prostatectomy

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of laparoscopic radical prostatectomy (LRP). However, robotic surgery is still fraught with potential difficulties and avoiding complications while on the steepest part of the learning curve is critical. Furthermore, as surgeons progress there is a tendency to take on increasingly complex cases, including patients with difficult anatomy and prior surgery, and these cases present a unique challenge. Significant intra-abdominal adhesions may be identified following open surgery, or dense periprostatic inflammation may be encountered following TURP; large prostate gland size and median lobes may alter bladder neck anatomy, making difficult subsequent urethro-vesical anastomosis. Even experienced robotic surgeons will be challenged by salvage RARP. Approaching these problems in a structured manner allows many of the problems to be overcome. We discuss some of the specific techniques to deal with these potential difficulties and highlight ways to avoid making serious mistakes.

AVOIDING AND DEALING WITH THE COMPLICATIONS OF ROBOT- ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY

B J U I N T E R N A T I O N A L

Does robotically assisted radical prostatectomy result in better preservation of erectile function

Accepted for publication 30 March 2006 signaling in SW480 colon cancer cells. Biochem Biophys Res Commun 2005; 328: 227–34 11 Kirby RS, Fitzpatrick JM. How should we advise patients about the chemoprevention of prostate cancer? BJU Int 2005; 96: 231–2 12 Gardner SH, Hawcroft G, Hull MA. Effect of nonsteroidal anti-inflammatory drugs on beta-catenin protein levels and catenin-related transcription in human colorectal cancer cells. Br J Cancer 2004; 91: 153–63

Prevention and management of haematomata after minimally invasive radical prostatectomy.

Bleeding and subsequent haematoma formation can be a troublesome problem during and after radical prostatectomy, whichever way it is performed. The recent advent of laparoscopic radical prostatectomy, with or without robotic assistance, has significantly reduced intra-operative blood loss; however, after surgery haematomata may still develop, most often in the prostatic bed between the bladder and the rectum. In this location a sizeable blood clot may cause pain and tenesmus and discharge through the anastomosis into the bladder, resulting in haematuria, often with troublesome clots. It may also distort or even disrupt the anastomosis and significantly delay healing and hence time to catheter removal and the restoration of normal voiding.

Congenital anterior urethral diverticulum in a male teenager: a case report and review of the literature.

We present the case of a 13-year-old boy with a congenital anterior urethral diverticulum. This is a rare condition in males which can lead to obstructive lower urinary tract symptoms and urosepsis. Diagnosis is by urethroscopy and radiological imaging. Surgical treatment can be open or endoscopic. Long-term followup is required to check for reoccurrence of the obstruction.

Learning the lessons from 1000 robot-assisted radical prostatectomy procedures

It has been observed that, unlike those involved in the aviation industry, clinicians are often slow to learn from their mistakes [1]. Having recently completed the 1000th robot-assisted radical prostatectomy (RARP) in one institution, as treatment for clinically significant, localized prostate cancer, we thought it would be useful to share the lessons learned from dealing with problems and complications we have encountered. Our technique has continuously evolved with various refinements along the way.